Infective Endocarditis in Patients with End-Stage Renal Disease on Dialysis: Epidemiology, Risk Factors, Diagnostic Challenges, and Management Approaches

Abstract

Infective endocarditis (IE) poses a significant clinical challenge, especially among patients with end-stage renal disease (ESRD) undergoing dialysis, and is associated with high morbidity and mortality rates. This review provides a contemporary discussion of the epidemiology, risk factors, diagnostic challenges, and management strategies for IE among ESRD patients, including a literature review of recent studies focused on this vulnerable population. The review highlights the multifactorial nature of IE risk in ESRD patients, emphasizing the roles of vascular access type, dialysis modality, and comorbid conditions. It also explores the diagnostic utility of different imaging modalities and the importance of a multidisciplinary approach in managing IE, including both medical and surgical interventions. The insights from this review aim to contribute to the improvement of patient outcomes through early recognition, appropriate antimicrobial therapy, and timely surgical intervention when necessary.

Keywords: cardiovascular imaging; dialysis; end-stage renal disease; infective endocarditis.

Figure 1

Central Illustration: Approach to diagnosis and patient-centered medical and surgical management in dialysis patients with infective endocarditis.

Figure 2

Mitral valve endocarditis in a patient with end-stage renal disease. Color-compare images from transesophageal (top panel) and transthoracic (bottom panel) echocardiograms demonstrating a large mobile vegetation on the posterior leaflet of the mitral valve associated with chordal rupture, leaflet flail, and severe mitral regurgitation. Images obtained from a dialysis patient with infective endocarditis due to Enterococcus Faecalis bacteremia from tunneled-dialysis catheter that had not been removed after arteriovenous fistula (AVF) maturation.

Figure 3

Aortic valve involvement in a patient with end-stage renal disease and endocarditis. Color-compare transesophageal echocardiographic image showing a long-axis view of the left ventricle (two-dimensional image shown on the left panel; color Doppler focused on the aortic valve shown on the right panel). The aortic valve leaflets are thickened and exhibit a mobile echodensity, as well as severe aortic regurgitation, most likely due to leaflet perforation. Image is taken from a dialysis patient with infective endocarditis secondary to Enterococcus Faecalis bacteremia from tunneled-dialysis catheter that had not been removed after arteriovenous fistula (AVF) maturation.

Figure 4

TEE 3D MV showing large mobile vegetation in a patient with end-stage renal disease and endocarditis. Transesophageal echocardiographic three-dimensional reconstruction of the mitral valve, view from the left atrium. A large mobile echodensity, consistent with vegetation, is attached to the P2 scallop of the mitral valve and prolapses into the left atrium during systole. Image is taken from a dialysis patient with infective endocarditis secondary to Enterococcus Faecalis bacteremia from tunneled-dialysis catheter that had not been removed after arteriovenous fistula (AVF) maturation.

Figure 5

Summary of the 2023 European Society of Cardiology (ESC) Guidelines for Management of Endocarditis and the 2020 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Patients with Valvular Heart Disease class indications and recommendations for different imaging modalities [8,41,45,55,56].